Original articleThe Spanish Pancreatic Club's recommendations for the diagnosis and treatment of chronic pancreatitis: Part 2 (treatment)
Introduction
The objective, justification and methodology of this consensus are explained in the first part of the consensus: “Spanish Pancreatic Club recommendations for the diagnosis and treatment of chronic pancreatitis: part 1 (diagnosis)”. Briefly, two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in Chronic Pancreatitis (CP). A list of questions was made, and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts and in a face-to-face meeting. The degree of scientific evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine [1].
Section snippets
Which is the optimal pharmacological treatment for pain in chronic pancreatitis?
Before addressing the treatment of CP-related pain, one must rule out other possible coexisting causes, such as the presence of pseudocysts, gastric or pancreatic neoplasms, peptic ulcer disease or biliary lithiasis. It is also desirable to eliminate the cause of CP, such as alcohol or tobacco use and ductal obstruction or to provide treatment for autoimmune pancreatitis. There are few high-quality studies on the treatment of CP-related pain. Pain-relieving drugs should be administered at
What kind of endoscopic treatment is available for CP-related pain? What is the role of extracorporeal shock wave lithotripsy in the treatment of patients with CP?
Invasive pain treatment for patients with CP is indicated when medical treatment fails or when it is necessary to resort to long-term opioid administration. Endoscopic decompression treatment (EDT) is an option for treating pain in patients with dilated main pancreatic duct (increased ductal pressure) and in patients with an obstructive stones or stenosis of the ductal system [23], [24]. When recommending EDT for pain, the clinician must take into account a number of limitations: 1) Randomized
Which are the surgical treatments for pain?
Surgery in patients with CP is indicated in three scenarios: disabling pain, when pancreatic cancer is suspected and in certain CP complications.
There is no validated threshold for indicating surgery for pain control [50]. Currently there is not any available randomized controlled trial comparing surgery with conservative treatment or different timing for surgery. As stated previously we recommend considering invasive treatment in patients with pain under treatment with strong opioids that will
Which are the other interventional treatment options for chronic pancreatitis-related pain?
In general, patients with a dilated duct are candidates for endoscopic or surgical decompression, which have been addressed previously in this consensus. However, the interventional techniques that are indicated in patients without duct dilation are discussed in this section. Celiac plexus blockade has been discussed previously. These interventional techniques may also be used when decompression treatments fail. The evidence for its use is scant. Published studies lack a control group.
Bilateral
Treatment options for pancreatic pseudocyst and its complications
A pancreatic pseudocyst is a collection of fluid with high concentration of amylase, surrounded by fibrous tissue. Most studies do not distinguish between pseudocysts in acute and chronic pancreatitis and include few patients, making decision-making guidelines difficult. Most pseudocysts are small and asymptomatic [83]. Pseudocysts associated with CP are less likely to resolve spontaneously than are those associated with other disorders.
Thirty-nine per cent of pseudocysts in CP evolve to
How should CP-related biliary stenosis and duodenal stenosis be treated?
The incidence of biliary stenosis in patients with CP is variable; it may affect up to 60% of patients with a pancreatic head mass [96]. Jaundice often resolves spontaneously within the first month in 20–50% of cases, but spontaneous resolution is more unlikely the longer the jaundice persists [97], [98], [99], [100], [101]. Cholangitis occurs in 10% of cases [96].
The following have been proposed as indications of biliary drainage in CP: cholangitis episodes, a progressive increase of biliary
The diagnosis and treatment of CP-related fistulae and ascites
The communication between the pancreatic ductal system (often after the rupture of a pseudocyst) and the abdominal cavity produces pancreatic ascites, and communication with the pleural cavity produces pleural effusion. The pancreatic origin can be confirmed by elevated levels of amylase (>1000 U/L). In these cases, ERCP or magnetic resonance cholangiopancreatography (MRCP) are useful imaging techniques that sometimes help to determine the source of the leak [108], [109].
In these situations,
How to manage left portal hypertension caused by thrombosis or splenic vein stenosis
Left portal hypertension (LPH) is a syndrome of which the most serious clinical consequence is gastrointestinal bleeding caused by gastric varices. This syndrome is secondary to splenic vein obstruction [117] in most cases, being caused by thrombosis that develops during the progression of CP [118].
In most cases, the diagnosis of gastric varices can be made using conventional endoscopy. EUS can increase the diagnostic sensitivity [119]. Little is known about the natural history of patients with
Which treatment peculiarities are particular to diabetes mellitus secondary to chronic pancreatitis?
Diabetes mellitus related to CP (DM-CP) differs from DM Types 1 and 2 because it carries a greater risk of hypoglycemia resulting from the altered secretion of glucagon, which is particularly problematic in patients with inadequate compliance, alcohol consumption or autonomic neuropathy [130]; however, it is also associated with a reduced risk of diabetic ketoacidosis. Management can be difficult, especially in the advanced stages of endocrine insufficiency and after pancreatic surgery [131].
How to treat exocrine pancreatic insufficiency and how to monitor the treatment
Exocrine pancreatic insufficiency (EPI) treatment is based on the oral replacement of pancreatic enzymes to optimize the process of digesting and absorbing nutrients. Although fat, carbohydrate and protein maldigestion may occur during EPI, most authors have primarily addressed steatorrhea because it is considered an early and frequent occurrence in CP [136], [137]. Initially, oral enzyme therapy should be recommended in patients who have exhibited frank steatorrhea (>15 g/day) [138] or
Nutritional support in chronic pancreatitis: how to detect, prevent and treat the nutritional deficit
The most important underlying mechanism for malnutrition is EPI; other factors include the increase in basal energy expenditure, the coexistence of abdominal pain, diabetes and alcohol abuse [145]. Thus, it is common to find a deficit of liposoluble vitamins [146], [147], [148], [149], [150], calcium, zinc [151], [152] and, occasionally, vitamin B12 [153].
Because of this high risk of malnutrition, it is imperative to perform a thorough nutritional status assessment that includes weight,
Conclusions
The Spanish Pancreatic Club has developed the present Consensus to guide the management of CP. The paucity of well- designed randomized controlled trials, the heterogeneity of available data, and the methodological flaws of published studies are reflected in the number of grade D recommendations: 8 out of 34 (23.5%), similar to previous consensus [161]. We recommend a step-up approach to medical management of CP-related pain, based in the WHO method for pain relief, detailed in Fig. 1. The most
Conflicts of interest
Enrique de-Madaria, Enrique Domínguez-Muñoz, Julio Iglesias-García and José Lariño-Noia have been paid speakers for Abbott Laboratories. Enrique Domínguez-Muñoz is a consultant for Abbott Laboratories and Pentax. Julio Iglesias-García is a consultant for Cook Medical Company. Luis Gómez and Yolanda Sastre have been paid speakers for Mundipharma, Zambon, Ferrer Pharma and Grunenthal Pharma. José Ramón Aparicio is a consultant for Boston Scientific.
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